■ Physician service during the war on terror presents a dual-loyalty dilemma that medical schools should address, experts say.

Medical students get a failing grade on their knowledge of physicians' ethical obligations during wartime, according to a new study authored by a team of Harvard Medical School physicians.

The authors said their study, published in October in the International Journal of Health Services, should prompt medical schools to educate future doctors more thoroughly on the ethical questions they could face in an age of terror and torture.

But experts said that although medical curricula could cover military medical ethics, such instruction should be folded into discussions about the broader problem of dual loyalty -- when doctors' advocacy for the patient conflicts with other institutional or societal objectives.

Medical students should be taught how they can -- and should -- stand up to health plans, drugmakers, the government or any other entity that asks physicians to violate medical ethics.

The American Medical Association supports comprehensive medical education that keeps pace with the ethical challenges facing physicians, AMA Board of Trustees Chair Edward L. Langston, MD, said in a statement responding to the study.

"Although relatively few physicians will face situations where they need to know the specific terms of the Geneva Conventions," Dr. Langston added, "the rules of military medical ethics provide important guidance on how physicians should handle situations of dual loyalties, which can affect all physicians."

About a third of students who responded to the researchers' survey did not know that under the Geneva Conventions, physicians are obligated to treat the sickest individuals first, regardless of nationality, and should refrain from participating in coercive interrogations or depriving prisoners of food and water. Almost two-thirds of the nearly 1,800 students from eight U.S. medical schools who took the quiz did not know that the Geneva Conventions apply to all signatories, regardless of whether they declare war officially.

The study's lead author is J. Wesley Boyd, MD, clinical instructor of psychiatry at Harvard and an attending psychiatrist at the Cambridge Health Alliance. Dr. Boyd said he and his colleagues, frustrated by physicians' seeming apathy toward the Iraq war, undertook the survey to find out how much students know about military medical ethics and a 1987 federal law that lays out the process for drafting doctors into the military. (Only 3.5% of respondents were aware of the draft law, known as the Health Care Personnel Delivery System.)

"The standout figure from the study, for me, is that 94% of medical students had less than one hour of teaching about military medical ethics or the Geneva Conventions," Dr. Boyd said, "especially when we're at war, when torture is in the daily news and when there is so much double-talk coming out of Washington in general about what constitutes torture."

One question asked whether a physician would be ethically required to disobey orders to threaten prisoners with a lethal injection, inject psychoactive drugs or actually administer a fatal cocktail. Nearly 30% of the respondents said only the lethal injection order could be disobeyed; the Geneva Conventions say all of the orders are unethical and must be disobeyed.

Ethics in the field

The study comes on the heels of alleged physician complicity in coercive interrogations that were employed at the U.S. Guantanamo Naval Base and in the war zones in Iraq and Afghanistan. The Dept. of Defense has acknowledged that military doctors participate in force-feeding hunger-striking Guantanamo prisoners, in apparent contradiction of the World Medical Assn.'s 1975 Declaration of Tokyo.

Dr. Boyd argued that even two hours of military medical ethics instruction would give tomorrow's physicians the wherewithal "to push back against a commander who orders them to do something that's unethical."

About 70% of military physicians graduate from nonmilitary medical schools, according to The Wall Street Journal. Doctors receive an intensive orientation that covers medical ethics when they join the armed forces.

Medical students at the Uniformed Services University of the Health Sciences in Bethesda, Md., receive ethics instruction in the classroom that gets tested in field exercises, said Edmund G. Howe, MD, director of the Programs in Ethics there. They may be ordered, for example, to treat an American's less-serious wounds before attending to a more gravely injured enemy soldier. If a student obeys the order -- which contradicts the Geneva Conventions -- they fail that portion of the test.

"My bias is that everybody in every medical school should know you are supposed to treat prisoners with dignity and equality," Dr. Howe said.

Steven Miles, MD, author of Oath Betrayed: Torture, Medical Complicity, and the War on Terror, said medical students should graduate with enough ethical education to stiffen their resolve when institutions such as the military, HMOs or drugmakers ask them to do the wrong thing.

"The U.S. military medical system's reputation has been tremendously hurt by doctors' failure to push back on things done in the war on terror," said Dr. Miles, professor of medicine and bioethics at the University of Minnesota Medical School. "Professionalism education may not need to include the Geneva Conventions, specifically, but it does need to cover the question of why a professionalism spine is required and the price that has to be paid to use it."

Dr. Miles and other human rights experts said education alone cannot steel physicians against unethical orders. They also need institutional support within the military and vociferous backing from organized medicine groups such as the AMA.

In 2006, the AMA adopted ethical policy barring doctors from participating in coercive interrogations. The Association also has policy opposing torture and endorsing the Declaration of Tokyo's prohibition on physician participation in torture.

ADDITIONAL INFORMATION

Lack of familiarity

A team of Harvard Medical School researchers quizzed nearly 1,800 students at eight U.S. medical schools about their knowledge of physicians' ethical duties during military conflicts, as specified in the Geneva Conventions. Only 5.7% of respondents said they were "very familiar" with the Geneva dictates, unsurprising considering that 94.2% of them had received less than an hour's instruction in military medical ethics. Below are the percentages of medical students surveyed who correctly understood the following principles:

37.4% The Geneva Conventions apply, regardless of whether war has been officially declared.

66.2% The sickest individuals should be treated first, no matter their nationality.

63% It is wrong to hurt, threaten or withhold food and water from prisoners being interrogated.

66.1% When it is permissible, disobey unethical military orders.

Source: "U.S. Medical Students' Knowledge About the Military Draft, the Geneva Conventions and Military Medical Ethics," International Journal of Health Services, Volume 37, No. 4.

The essentials

The Geneva Conventions and Additional Protocols govern the treatment of prisoners of war, captured combatants and civilians. There are three "essential rules" relating to physicians, as distilled by the International Committee of the Red Cross:

It is forbidden to kill or wound an adversary who surrenders or who can no longer take part in the fighting.

The wounded and sick must be collected and cared for by the party to the conflict which has them in its power.

Captured combatants and civilians who find themselves under the authority of the adverse party are entitled to respect for their lives, their dignity, their personal rights and their political, religious and other convictions. They must be protected against all acts of violence or reprisal.

Also, the World Medical Assn.'s Declaration of Tokyo bars physicians from participating in or facilitating torture, which includes the force-feeding of competent hunger-striking prisoners. Physicians should report violations of the Geneva Conventions, the Declaration says.

Sources: International Committee of the Red Cross, World Medical Assn.